Cartilage degeneration of patellofemoral joint occurs in open wedge high tibial osteotomy, rather than in hybrid closed wedge high tibial osteotomy, during the early postoperative period: A qualitative analysis using MRI T2 mapping.

PURPOSE: After high tibial osteotomy, the patella may change position and osteoarthritis of the patellofemoral joint (PFJ) may occur. It was hypothesized that the course of PFJ degeneration would differ between open wedge high tibial osteotomy (OWHTO) and hybrid closed wedge high tibial osteotomy (hybrid HTO). Accordingly, this study aimed to evaluate the qualitative changes in PFJ articular cartilage, during the early postoperative period after OWHTO and hybrid HTO. METHODS: This was a retrospective observational study of 75 knees that underwent OWHTO (N = 37) or hybrid HTO (N = 38) for medial knee osteoarthritis. OWHTO and hybrid HTO were indicated for corrections of less than 10° and more than 10°, respectively. MRI of all knees was performed before and 6 months after surgery to evaluate patellar cartilage in sagittal images for T2 mapping. Three regions of interest (medial, middle, and lateral facets) were defined in the articular cartilage, and T2 values were measured. Patellar tilting angle, lateral shift ratio, and patellar height were compared before and after surgery. RESULTS: There was no significant change in arthroscopic findings of PFJ articular cartilage between the OWHTO and hybrid HTO groups. In the OWHTO group, the mean T2 value of medial and middle facets increased significantly (lateral, 43.0 ± 3.9 to 43.7 ± 3.5; middle, 44.2 ± 3.9 to 46.2 ± 3.8; medial 41.0 ± 4.3 to 42.4 ± 4.0). Conversely, no significant change was observed in the hybrid HTO group (lateral, 41.1 ± 4.0 to 42.3 ± 4.0; middle, 43.6 ± 4.2 to 44.5 ± 4.3; medial, 40.7 ± 4.1 to 41.5 ± 4.5). Patellar height decreased and increased in the OWHTO and hybrid HTO groups, respectively, and patellar tilt decreased in the OWHTO group. Lateral shift ratio decreased significantly in both groups. CONCLUSIONS: OWHTO with a small correction angle may result in qualitative changes in PFJ articular cartilage from an early stage, while hybrid HTO with a relatively large correction angle is unlikely to affect PFJ articular cartilage.

Revision Anterior Cruciate Ligament Reconstruction Using Semitendinosus Tendon With Bone Fragment.

After anterior cruciate ligament (ACL) reconstruction, the tibial tunnel becomes widened over time. A revision surgery of the ACL reconstruction is required to fill the widened tunnels. Bone-patellar tendon-bone grafts often are used to fill enlarged bone tunnels. However, due to the variation in tendon length, it is often difficult to adjust the position of the bone fragment to the enlarged part of the bone tunnel. This study describes an arthroscopic ACL reconstruction technique using the semitendinosus tendon as well as a bone fragment which is placed in the enlarged tibial tunnel. The tendon and cortical bone were collected together at the tendon attachment using a flat chisel. The bone fragment was inserted through the tendon in a controlled manner and ultimately placed at the posterior wall of the tibial foramen. This technique was determined to be less invasive than using bone-patellar tendon-bone in a 2-stage revision ACL reconstruction. In addition, this technique can be easily performed by any surgeon who is accustomed to conventional ACL reconstruction using the semitendinosus tendon and does not require any special equipment. Our findings suggest that this technique may be useful for revision ACL reconstruction.

Clinical outcomes after medial patellofemoral ligament reconstruction: an analysis of changes in the patellofemoral joint alignment.

PURPOSE: Medial patellofemoral ligament (MPFL) reconstruction using the hamstring tendon is widely performed to treat recurrent patellar dislocation. MPFL reconstruction includes a post-operative process of necrosis and reperfusion of the hamstring tendon graft. We hypothesise that the patella gradually shifts laterally because of this process, ultimately affecting the patellofemoral joint alignment. This study aimed to analyse the chronological changes in the patellofemoral joint alignment and the outcomes of MPFL reconstruction. METHODS: In this retrospective case-series study, the Knee Society, Lysholm, and Kujala scores were evaluated in 24 consecutive patients (27 knees). To evaluate patellar tracking defects, radiographic indices including the tilting angle, the lateral shift ratio, and the congruence angle were measured before, immediately after, and three, 12, and 36 months after MPFL reconstruction. RESULTS: Post-operative Kujala, Knee Society, and Lysholm scores for the study population significantly improved relative to the pre-operative scores. The tilting and congruence angles at three months after the operation significantly increased relative to those recorded immediately after the operation. The tilting and congruence angles were not significantly different at three, 12, and 36 months after the operation. CONCLUSIONS: The post-operative outcomes of MPFL reconstruction for recurrent patellar dislocation were favourable. Insufficient union between the bone tunnel and tendon graft, along with an elongation of the necrotic tendon graft, may change the alignment of the patellofemoral joint within three months after the operation. Therefore, we believe it is necessary to refrain from knee rotation that places lateral stress on the patella until three months after the operation.

Arthroscopic Fixation Technique for Avulsion Fracture of the Posterior Cruciate Ligament From the Tibia.

This study describes an arthroscopic pullout fixation technique for small and comminuted avulsion fractures of the posterior cruciate ligament from the tibia. Intra-articular surgery required 3 arthroscopic portals, the anterolateral, anteromedial, and posteromedial portals. To simplify surgery, the posterolateral portal was omitted. A 2.4-mm K-wire was inserted through the anterior incision to the center of the bone fragment. This central guidewire was subsequently overdrilled with a 4.0-mm cannulated drill. The fixation material consisted of Pass Telos artificial ligaments inserted through the fiber loop of a fixed suspensory device such as RIGIDLOOP. The leading end of the thread of the RIGIDLOOP was pulled out through the anteromedial portal. The button of RIGIDLOOP was gradually advanced through the bone tunnel. The button was pulled out and flipped over the bony fragment. The artificial ligament was pulled distally to reduce the bony fragment, and fixed onto the tibia using a ligament button while applying anterior drawer force to the proximal tibia with the knee flexed at 90°. This minimally invasive procedure was successful in treating small and comminuted avulsion fracture of the tibial attachment of the posterior cruciate ligament.

Extensor hallucis longus tendon is a new distal landmark for coronal tibial component alignment in total knee arthroplasty: A study of magnetic resonance imaging.

PURPOSE: In total knee arthroplasty (TKA), various landmarks are generally used to ensure correct osteotomy. In this study, we examined whether the tibialis anterior tendon (TAT) or the extensor hallucis longus tendon (EHLT) could be used as a landmark of the center of the ankle joint in patients with knee osteoarthrosis (OA), using magnetic resonance imaging (MRI). METHODS: The subjects were 61 patients with OA in 79 knees (males: 8 with 9 knees and females: 53 with 70 knees). With the ankle joint secured in the intermediate position, MRI from the knee joint to the ankle joint was performed in the same foot position. We prepared individual lines connecting the center of the ankle joint with the TAT or EHLT to measure the angle difference (ΔA) from Akagi's line in the knee joint. We analyzed whether the ΔA might be affected by deformity of the knee joint or foot region, and tibial torsion. RESULTS: At the ankle joint level, the ΔA of EHLT was the smallest, with an average of 1.6 ± 3.4°. The ΔA for the femorotibial angle, hallux valgus angle, and varus-valgus angle showed no correlations with deformity of the knee joint and foot region, or tibial torsion. CONCLUSIONS: MRI findings showed that EHLT would be useful as a landmark of the ankle joint center in extramedullary tibial osteotomy in TKA for medial knee OA. It was also clarified that the landmark would not be affected by severe deformity of the knee joint, deformity of the foot region, or external torsion of the tibia.

Outcome of Low-Invasive Local Split-Thickness Lengthening for Iliotibial Band Friction Syndrome.

Conventional surgical methods for iliotibial band friction syndrome (ITBFS) may affect the iliotibial band (ITB), delaying return to sports activities or impeding performance. We have developed a minimally invasive method. This study retrospectively analyzed the outcomes of this procedure in individuals with ITBFS. This study included 34 knees of 31 individuals. Surgery involved lengthening the central part of the ITB by splitting it into a superficial and a deep layer, maintaining the anterior and posterior fibers immediately above the lateral epicondyle. Outcomes included time to resume sports activity, personal best times to run a 5000-m race before and after surgery, and 2-month post-surgery muscle strengths. The mean postoperative time to return to competition was 5.8 weeks. Personal best times of 5000-m race improved in 13 of 17 runners. Two months post-surgery, the mean extensor muscle strengths on the healthy and affected sides did not significantly differ nor did the flexor muscle strengths. In ITBFS, the ITB itself is normal. Lengthening the limited region of the ITB immediately above the lateral femoral epicondyle removes the cause of ITBFS, with a reduction in inflammation. This technique resulted in early return to competition without degrading performance.

Length change patterns and shape of a grafted tendon after anatomical medial patellofemoral ligament reconstruction differs from that in a healthy knee.

PURPOSE: Recurrent patellar dislocation is currently treated with anatomical reconstruction of the medial patellofemoral ligament (MPFL), and favourable postoperative outcomes have been reported. However, it is uncertain if healthy MPFL function is restored by anatomical reconstruction. The hypothesis in this study was that stabilization of the patella following MPFL reconstruction would be improved compared with that before surgery, but that function of the grafted tendon would differ from that of a healthy MPFL. The objective was to analyse the length change patterns of the MPFL before surgery and the grafted tendon after surgery in patients with recurrent patellar dislocation treated with anatomical MPFL reconstruction. METHODS: The subjects were 12 patients (13 knees) in whom recurrent patellar dislocation was treated with anatomical MPFL reconstruction. The length change patterns of the MPFL and reconstructed ligament were analysed at extension and flexion of the knee joint using open MRI. RESULTS: The postoperative grafted tendon length was significantly shorter than that of the preoperative MPFL at knee extension, and significantly longer at 90° and 120° of knee flexion. The postoperative length of the grafted tendon only changed slightly from 0° to 30° of knee flexion, and then significantly decreased at flexion of 30° or more. The morphology of the grafted tendon was linear until 60° knee flexion, but became convex toward the extraarticular side at flexion of 90° or more. CONCLUSION: The grafted tendon length at knee extension was shorter than that of the preoperative MPFL, but there was no significant difference at 30° flexion. These findings suggest that the effect of damping of the patella with a grafted tendon after MPFL reconstruction may differ from that in a healthy knee. In addition, the morphology at 60° knee flexion was improved to linear after surgery, suggesting that ligament morphology at this flexion was normalized by MPFL reconstruction. LEVEL OF EVIDENCE: III.

Fixed-flexion view X-ray of the knee superior in detection and follow-up of knee osteoarthritis.

A fixed flexion view (FFV) is useful for evaluating joint space when assessing the severity of osteoarthritis (OA) of the knee. We analyzed changes in joint space revealed by standing extended view (SEV) and FFV over a mean 4 years, to compare both views on their capacity to measure joint space width accurately at particular time points during follow-up.SEV and FFV images were acquired in patients with knee OA. The 81 patients (157 knees) followed up for ≥24 months were selected as study subjects. Medial joint space widths (MJSW), Kellgren-Lawrence (KL) grades, and reductions in MJSW on SEV (ΔSEV) and FFV (ΔFFV) were compared in knees evaluated by SEV and FFV.At both time-points, mean MJSW was significantly lower by FFV than by SEV. Mean MJSW was significantly lower at follow-up than at first examination by both SEV and FFV. At both time-points, the KL grade was higher by FFV than by SEV group. The ΔFFV was significantly greater than the ΔSEV. ΔSEV did not differ significantly among KL grades, but ΔFFV was significantly greater in patients with KL grade II than in patients with other KL grades.FFV is not only useful for evaluating joint space in knees with OA, but also for accurately evaluating the progression of OA. The risk of rapid progression of knee OA may be higher in patients with KL grade II, as determined by FFV. FFV may be superior to SEV in determining appropriate treatment strategies for knee OA.

Arthroscopic Pullout Fixation for a Small and Comminuted Avulsion Fracture of the Posterior Cruciate Ligament from the Tibia.

We describe a patient who underwent arthroscopic pullout fixation for a posterior cruciate ligament (PCL) avulsion fracture. A 46-year-old female, injured in a fall while riding a motorcycle, was diagnosed with a right knee PCL tibial attachment avulsion fracture and underwent arthroscopic osteosynthesis. A Kirschner wire was drilled to a point just medial to the medial border of the anterior tibial bony bed. A suture wire was folded into a loop and introduced into the posteromedial compartment via the bone tunnel. A fixation thread was inserted from the posteromedial portal, through the medial and lateral loop wires, and into the posteromedial compartment. The lateral and medial loop wires attached to the thread were pulled to the outside, and the thread was fixed onto the tibia. Three months post-surgery, she returned to her job. This procedure represents a minimally invasive method of treating avulsion fractures of the tibial attachment of the PCL.

Radiographic Measurement of Joint Space Width Using the Fixed Flexion View in 1,102 Knees of Japanese Patients with Osteoarthritis in Comparison with the Standing Extended View.

PURPOSE: The fixed flexion view (FFV) of the knee is considered useful for evaluating the joint space when assessing the severity of osteoarthritis (OA) of the knee. To clarify the usefulness of FFV for evaluation of the joint space and severity of knee OA, this study evaluated changes in the joint space on the FFV and standing extended view (SEV) in patients with knee OA. MATERIALS AND METHODS: The SEV and FFV images were acquired in 567 patients (1,102 knees) who visited the hospital with a chief complaint of knee joint pain. Medial joint space width (MJSW) and Kellgren-Lawrence (K-L) classification assessed using the SEV and FFV images were compared. RESULTS: Mean MJSW was significantly smaller when assessed on the FFV than on the SEV (3.02±1.55 mm vs. 4.31±1.30 mm; p<0.001). The K-L grade was the same or higher on the FFV than on the SEV. CONCLUSIONS: The FFV is more useful than the SEV for evaluating the joint space in OA knees. Treatment strategies in patients with knee OA should be determined based on routinely acquired FFV images.

Comparative Effects of Periarticular Multimodal Drug Injection and Single-Shot Femoral Nerve Block on Pain Following Total Knee Arthroplasty and Factors Influencing Their Effectiveness.

PURPOSE: This study compared the analgesic effects of local infiltration analgesia (LIA) and femoral nerve block (FNB) after total knee arthroplasty (TKA) and assessed factors associated with analgesia obtained by these two methods. MATERIALS AND METHODS: Study subjects included 66 patients (72 knees) who underwent TKA for osteoarthritis of the knee. Pain visual analogue scale (VAS), the amount of analgesics used, number of days to achieve 90° of flexion of the knee joint, date of initiating parallel-bar walking, range of motion of the knee joint at discharge, and adverse events were investigated. RESULTS: The VAS scores did not differ significantly between two groups, whereas the amount of analgesics used was significantly lower in the LIA group. Preoperative flexion contracture was significantly more severe in the LIA group with high VAS compared with low VAS. No serious adverse event occurred in the LIA or FNB group. CONCLUSIONS: The lower analgesic usage in the LIA group than the FNB group indicates that the analgesic effect of LIA was greater than that of singleshot FNB after TKA. There were no serious complications in either group. The postoperative analgesic effect of LIA was smaller in patients with severe than less severe preoperative flexion contracture.